causes ,mechanism and drugs for treatment of arrhythmias

2. Normal conduction pathway:
1- SA node generates
action potential and
delivers it to the atria
and the AV node
2- The AV node
delivers the impulse
to purkinje fibers
3- purkinje fibers
conduct the impulse
to the ventricles

3. Action potential of the heart:
In the atria,
purkinje, and
ventricles the AP
curve consists of
5 phases
In the SA node
and AV node, AP
curve consists of
3 phases

4. Non-pacemaker action potential
Phase 0: fast
upstroke
Due to Na+
influx
Phase 3:
repolarization
Due to K+
efflux
Phase 4: resting
membrane potential
Phase 2: plateu
Due to Ca++
influx
Phase 1: partial
repolarization
Due to rapid efflux of K+
N.B. The slope of phase 0 = conduction velocity
Also the peak of phase 0 = Vmax

5. Pacemaker AP
Phase 4: pacemaker
potential
Na influx and K efflux
and Ca influx until the
cell reaches threshold
and then turns into
phase 0
Phase 0: upstroke:
Due to Ca++
influx
Phase 3:
repolarization:
Due to K+
efflux
Pacemaker cells (automatic cells) have
unstable membrane potential so they can
generate AP spontaneously

6. Effective refractory period (ERP)
It is also called absolute refractory period
(ARP) :
•In this period the cell can’t be excited
•Takes place between phase 0 and 3

7. Arrhythmia
If the arrhythmia
arises from the
ventricles it is
called ventricular
arrhythmia
If the arrhythmia
arises from atria,
SA node, or AV
node it is called
supraventricular
arrhythmia

8. Mechnisms of Arrhythmogenesis
Delayed
afterdepolarization
Early
afterdepolarization
↑AP from SA
node
AP arises from sites
other than SA node

9. This is when the
impulse is not
conducted from
the atria to the
ventricles
1-This
pathway is
blocked
2-The impulse
from this pathway
travels in a
retrograde fashion
(backward)
3-So the cells here will
be reexcited (first by the
original pathway and the
other from the
retrograde)

10. Here is an
accessory
pathway in the
heart called
Bundle of Kent
•Present only in small populations
•Lead to reexcitation  Wolf-Parkinson-White
Syndrome (WPW)
Abnormal anatomic conduction

11. Supraventricular Arrhythmias
 Sinus Tachycardia: high sinus rate of 100-180
beats/min, occurs during exercise or other conditions
that lead to increased SA nodal firing rate
 Atrial Tachycardia: a series of 3 or more consecutive
atrial premature beats occurring at a frequency >100/min
 Paroxysmal Atrial Tachycardia (PAT): tachycardia which
begins and ends in acute manner
 Atrial Flutter: sinus rate of 250-350 beats/min.
 Atrial Fibrillation: uncoordinated atrial depolarizations.
AV blocks
A conduction block within the AV node , occasionally in the
bundle of His, that impairs impulse conduction from the
atria to the ventricles.
Types of Arrhythmia

12.  Ventricular Premature Beats (VPBs): caused by
ectopic ventricular foci; characterized by widened QRS.
 Ventricular Tachycardia (VT): high ventricular rate
caused by abnormal ventricular automaticity or by
intraventricular reentry; can be sustained or non-
sustained (paroxysmal); characterized by widened QRS;
rates of 100 to 200 beats/min; life-threatening.
 Ventricular Flutter - ventricular depolarizations
>200/min.
 Ventricular Fibrillation - uncoordinated ventricular
depolarizations
ventricular Arrhythmias

13. Pharmacologic Rationale & Goals
 The ultimate goal of antiarrhythmic drug
therapy:
o Restore normal sinus rhythm and conduction
o Prevent more serious and possibly lethal
arrhythmias from occurring.
 Antiarrhythmic drugs are used to:
 decrease conduction velocity
 change the duration of the effective refractory
period (ERP)
 suppress abnormal automaticity

14. Antyarrhythmic drugs
class mechanism action notes
I Na+
channel blocker
Change the slope of
phase 0
Can abolish
tachyarrhythmia
caused by reentry
circuit
II β blocker
↓heart rate and
conduction velocity
Can indirectly alter K
and Ca conductance
III K+
channel blocker
1. ↑action potential
duration (APD) or
effective refractory
period (ERP).
2. Delay
repolarization.
Inhibit reentry
tachycardia
IV Ca++
channel blocker
Slowing the rate of rise
in phase 4 of SA
node(slide 12)
↓conduction velocity
in SA and AV node
•Most antiarrhythmic drugs are pro-arrhythmic (promote arrhythmia)
•They are classified according to Vaughan William into four classes according to their
effects on the cardiac action potential

15.  Slowing of the rate of rise
in phase 0  ↓conduction
velocity
 ↓of Vmax of the cardiac action
potential
 They prolong muscle action
potential & ventricular (ERP)
 They ↓ the slope of Phase 4
spontaneous depolarization
(SA node)  decrease
enhanced normal
automaticity
They make the
slope more
horizontal

16. Class IA Drugs
 They possess intermediate rate of association and
dissociation (moderate effect) with sodium channels.
Pharmacokinetics:

17. Class IA Drugs
Uses Supraventricular and ventricular arrhythmias
 Quinidine is rarely used for supraventricular
arrhythmias
 Oral quinidine/procainamide are used with class III
drugs in refractory ventricular tachycardia patients
with implantable defibrillator
 IV procainamide used for hemodynamically stable
ventricular tachycardia
 IV procainamide is used for acute conversion of
atrial fibrillation including Wolff-Parkinson-White
Syndrome (WPWS)
defibrillator

18. Class IA Drugs Toxicity
Systemic lupus erythromatosus (SLE)-like
symptoms: arthralgia, fever, pleural-
pericardial inflammation.
Symptoms are dose and time dependent
Common in patients with slow hepatic
acetylation

19. Notes:
Torsades de pointes: twisting of the point . Type of
tachycardia that gives special characteristics on ECG
At large dosesof quinidine  cinchonism occurs:blurred vision, tinnitus, headache,
psychosis and gastrointestinal upset
Digoxin is administered before quinidine to prevent the conversion of atrial fibrillation or
flutter into paradoxical ventricular tachycardia

20. Class IB Drugs
 They shorten Phase 3
repolarization
 ↓ the duration of the cardiac
action potential
 They suppress arrhythmias
caused by abnormal
automaticity
 They show rapid association &
dissociation (weak effect) with
Na+
channels with appreciable
degree of use-dependence
 No effect on conduction velocity

21. Agents of Class IB
Lidocaine
 Used IV because of extensive
1st
pass metabolism
 Lidocaine is the drug of choice
in emergency treatment of
ventricular arrhythmias
 Has CNS effects: drowsiness,
numbness, convulstion, and
nystagmus
Mexiletine
 These are the oral analogs of lidocaine
 Mexiletine is used for chronic
treatment of ventricular arrhythmias
associated with previous myocardial
infarction
Uses
They are used in the treatment of ventricular arrhythmias arising during myocardial
ischemia or due to digoxin toxicity
They have little effect on atrial or AV junction arrhythmias (because they don’t act on
conduction velocity)
Adverse effects:
1-neurological effects
2-negative inotropic activity

22. Class IC Drugs
 They markedly slow Phase 0 fast
depolarization
 They markedly slow conduction in
the myocardial tissue
 They possess slow rate of
association and dissociation
(strong effect) with sodium
channels
 They only have minor effects on
the duration of action potential
and refractoriness
 They reduce automaticity by
increasing the threshold potential
rather than decreasing the slope of
Phase 4 spontaneous
depolarization.

23. Uses:
 Refractory ventricular arrhythmias.
 Flecainide is a particularly potent suppressant of premature
ventricular contractions (beats)
Toxicity and Cautions for Class IC Drugs:
 They are severe proarrhythmogenic drugs causing:
1. severe worsening of a preexisting arrhythmia
2. de novo occurrence of life-threatening ventricular tachycardia
 In patients with frequent premature ventricular contraction (PVC)
following MI, flecainide increased mortality compared to placebo.
Notice: Class 1C drugs are particularly of low safety and have
shown even increase mortality when used chronically after MI

24. Compare between class IA, IB, and IC drugs as
regards effect on Na+
channel & ERP
 Sodium channel blockade:
IC > IA > IB
 Increasing the ERP:
IA>IC>IB (lowered) Because of
K+
blockade

25. Class II ANTIARRHYTHMIC DRUGS
(β-adrenergic blockers)
Uses
 Treatment of increased
sympathetic activity-induced
arrhythmias such as stress-
and exercise-induced
arrhythmias
 Atrial flutter and fibrillation.
 AV nodal tachycardia.
 Reduce mortality in post-
myocardial infarction patients
 Protection against sudden
cardiac death
Mechanism of action
 Negative inotropic
and chronotropic
action.
 Prolong AV
conduction (delay)
 Diminish phase 4
depolarization 
suppressing
automaticity(of
ectopic focus)

26. Class II ANTIARRHYTHMIC DRUGS
 Propranolol (nonselective): was proved to
reduce the incidence of sudden arrhythmatic
death after myocardial infarction
 Metoprolol
 reduce the risk of bronchospasm
 Esmolol:
 Esmolol is a very short-acting β1-adrenergic
blocker that is used by intravenous route in acute
arrhythmias occurring during surgery or
emergencies
selective

27. Class III ANTIARRHYTHMIC
DRUGS
K+
blockers
 Prolongation of phase 3
repolarization without altering
phase 0 upstroke or the resting
membrane potential
 They prolong both the duration
of the action potential and ERP
 Their mechanism of action is
still not clear but it is thought
that they block potassium
channels

28. Uses:
 Ventricular arrhythmias, especially ventricular
fibrillation or tachycardia
 Supra-ventricular tachycardia
 Amiodarone usage is limited due to its wide
range of side effects

29. Sotalol (Sotacor)
 Sotalol also prolongs the duration of action potential and
refractoriness in all cardiac tissues (by action of K+
blockade)
 Sotalol suppresses Phase 4 spontaneous depolarization and
possibly producing severe sinus bradycardia (by β blockade
action)
 The β-adrenergic blockade combined with prolonged action
potential duration may be of special efficacy in prevention of
sustained ventricular tachycardia
 It may induce the polymorphic torsades de pointes ventricular
tachycardia (because it increases ERP)
Ibutilide
Used in atrial fibrillation or flutter
IV administration
May lead to torsade de pointes
Only drug in class three that possess pure K+
blockade

30. Amiodarone (Cordarone)
 Amiodarone is a drug of multiple actions and is still not well understood
 It is extensively taken up by tissues, especially fatty tissues (extensive
distribution)
 t1/2 = 60 days
 Potent P450 inhibitor
 Amiodarone antiarrhythmic effect is complex comprising class I, II, III,
and IV actions
• Dominant effect: Prolongation of action potential duration and refractoriness
• It slows cardiac conduction, works as Ca2+
channel blocker, and as a weak
β-adrenergic blocker
Toxicity
 Most common include GI intolerance, tremors, ataxia, dizziness, and hyper-
or hypothyrodism
 Corneal microdeposits may be accompanied with disturbed night vision
 Others: liver toxicity, photosensitivity, gray facial discoloration, neuropathy,
muscle weakness, and weight loss
 The most dangerous side effect is pulmonary fibrosis which occurs in
2-5% of the patients

31. Class IV ANTIARRHYTHMIC DRUGS
(Calcium Channel Blockers(
 Calcium channel blockers decrease
inward Ca2+
currents resulting in a
decrease of phase 4 spontaneous
depolarization (SA node)
 They slow conductance in Ca2+
current-dependent tissues like AV
node.
 Examples: verapamil & diltiazem
Because they act on the heart only
and not on blood vessels.
 Dihydropyridine family are not used
because they only act on blood vessels

32. Mechanism of
action
 They bind only to depolarized (open) channels  prevention of repolarization
 They prolong ERP of AV node  ↓conduction of impulses from the atria to the
ventricles
So they act only in cases of arrhythmia because many Ca2+
channels are depolarized while in normal rhythm many of them
are at rest
More effective in treatment of atrial than ventricular arrhythmias.
Treatment of supra-ventricular tachycardia preventing the
occurrence of ventricular arrhythmias
Treatment of atrial flutter and fibrillation
Uses

33. contraindication
 Contraindicated in patients with pre-existing
depressed heart function because of their negative
inotropic activity
Adverse effects
 Cause bradycardia, and asystole especially when
given in combination with β-adrenergic blockers

34. Miscellaneous Antiarrhythmic
Drugs
Adenosine
o Adenosine activates A1-purinergic receptors
decreasing the SA nodal firing and automaticity,
reducing conduction velocity, prolonging
effective refractory period, and depressing AV
nodal conductivity
o It is the drug of choice in the treatment of
paroxysmal supra-ventricular tachycardia
o It is used only by slow intravenous bolus
o It only has a low-profile toxicity (lead to
bronchospasm) being extremly short acting for
15 seconds only

35. class ECG QT Conduction
velocity
Refractory
period
IA ++ ↓ ↑
IB 0 no ↓
IC + ↓ no
II 0 ↓In SAN and
AVN
↑ in SAN and
AVN
III ++ No ↑
IV 0 ↓ in SAN and
AVN
↑ in SAN and
AVN

36. 1st
: Reduce thrombus formation by using anticoagulant warfarin
2nd
: Prevent the arrhythmia from converting to ventricular arrhythmia:
First choice: class II drugs:
•After MI or surgery
•Avoid in case of heart failure
Second choice: class IV
Third choice: digoxin
•Only in heart failure of left ventricular dysfunction
3rd
: Conversion of the arrhythmia into normal sinus rhythm:
Class III:
IV ibutilide, IV/oral amiodarone, or oral sotalol
Class IA:
Oral quinidine + digoxin (or any drug from the 2nd
step)
Class IC:
Oral propaphenone or IV/oral flecainide
Use direct current in case
of unstable hemodynamic
patient

37. First choice: class II
•IV followed by oral
•Early after MI
Second choice: amiodarone
Avoid using
class IC after
MI  ↑
mortality
First choice: Lidocaine IV
•Repeat injection
Second choice: procainamide IV
•Adjust the dose in case of renal failure
Third choice: class III drugs
•Especially amiodarone and sotalol
Premature ventricular beat (PVB)

38. (IA, IC, class III)  torsades de pointes.
Classes II and IV  bradycardia (don’t combine the two)
In atrial flutter use (1st
↓impulses from atria to ventricular to prevent
ventricular tachycardia)
1.Class II
2.Class IV
3.Digoxi
2nd
convert atrial flutter to normal sinus rhythm use:
1.Ibutilide
2.Sotalol
3.IA or
If you use quinidine combine it with digoxin or β blocker (because of its anti
muscarinic effect)
Avoid IC in myocardial infarction because it ↑ mortality

39. THANK U